**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure nursing staff notified the resident representative when a resident had a significant change in condition for 1 (#1) of 3 (#1, #2, #3) sampled residents reviewed. Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, Drug Induced Subacute Dyskinesia, Type 2 Diabetes Mellitus, Dysphagia, Essential Hypertension, Primary Generalized Osteoarthritis, Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Stage 2, Schizophrenia, Unspecified, and Peripheral Vascular Disease Review of Resident # 1's MDS Assessment, with an ARD of 10/29/2024, revealed a BIMS Score of 01, indicating the facility assessed him to be severely cognitively impaired. Further review revealed he required extensive one person assistance for bed mobility/transfers. Review of Resident #1's Initial wound assessment completed 07/07/2025 at 12:30 p.m. by S2RN revealed the following, in part: Open lesion to left medial thigh, acquired in-house, new wound, wound measurements 12.0 cm x 8.7 cm x 2.0 cm, depth not applicable, tunneling not applicable, 100% of wound covered, surface intact, no evidence of infection, no exudate, edges attached, no induration, no edema, no pain. Treatment-generic wound cleanser, dry dressing, Practitioner notified, Responsible Party notified. On 02/04/2025 at 1:50 p.m., an interview was conducted with S2RN, wound care nurse. S2RN confirmed she documented she notified the Responsible Party for Resident #1 on 01/07/2025 regarding left upper thigh wound discovered but confirmed she did not notify the Responsible Party. On 02/04/2025 at 10:20 a.m., an interviewed was conducted with S1ADM. S1ADM confirmed S2RN had documented she had contacted Resident #1's Responsible Party after the initial wound assessment. S1ADM further confirmed it was the S2RN responsibility to notify Resident #1's Responsible Party of the change in condition and she did not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure alleged injuries of unknown origin were reported to the State Agency within the required time frame for 1 (#1 ) of 3 (#1, #2, and #3) sampled residents. The facility failed to report Resident #1's injury of unknown origin to the state agency within 24 hours of being made aware. Findings: Review of Resident #1's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses that included, Type 2 Diabetes Mellitus, Dysphagia, and Peripheral Vascular Disease. Review of Resident # 1's MDS Assessment, with an ARD of 10/29/2024, revealed a BIMS Score of 01, indicating the facility assessed him to be severely cognitively impaired. Review of Resident #1's Nurses Notes dated 01/06/2025 to 01/11/2025 revealed the following: On 01/11/2025 at 9:33 p.m., S3RN wrote: I was summoned to resident #1's room by S5CNA, stating that Resident #1's family was there and wanted to know what happened to his leg. Before speaking with the family, I reviewed the residence medical record to ascertain the origin of his injuries. I was unable to find any supportive data to the origin of injury to the left thigh. Family member stated Resident #1 stated that he spilled hot coffee on his leg. S1ADM was notified of my findings and series of events. Multiple attempts were made during survey to contact S3RN, without success. On 02/03/2025 at 10:09 a.m., a telephone interview was conducted with Resident #1's Responsible Party. She stated she was at the facility the evening of 01/11/2025 and during Resident's #1 incontinent care she saw he had a wound to his inter left thigh. She stated she questioned Resident #1 and he stated it was a coffee spill. On 02/04/2025 at 12:17 p.m., a telephone interview was conducted with S5CNA. He stated on 01/11/2025, during incontinent care, he notice a wound to Resident #1's left inner thigh. He stated skin was missing from the leg. He stated he immediately reported to S3RN. On 02/03/2025 at 3:45 p.m., an interview was conducted with S2RN wound care. She stated on 01/07/2025 she was notified of a small dry lesion to Resident #1's upper left thigh. She stated at the time of the initial assessment the lesion did not appear to be a burn or skin injury. She stated two days later when she assessed the wound, skin had sluffed off of the wound. She stated the wound care nurse practitioner was notified and treatments were continued. She stated she documented the wound as a burn on 01/13/2025 after family claimed Resident #1 alleged spilling coffee on his leg. She stated on 01/13/2025 she questioned the resident multiple times about how he obtained his wound and each time Resident #1 stated I don't know. She stated Resident #1 has a low BIMS and was unable to tell her exactly what happen. She stated she then ask if he had spilled coffee on himself and Resident #1 stated no, I wasted it. She stated the wound could have been a burn but she was unsure due to no witnesses. She stated she did not notify administration of Resident #1's injury of unknown origin. On 02/04/2025 at 3:25 p.m., an interviewed was conducted with S1ADM. S1ADM confirmed he was the person responsible for filing self-reported incidents to the state for the facility. S1ADM stated he was made aware of Resident #1's injury on 01/11/2025. S1ADM further confirmed no self-reported incident to the state was filed regarding injury of unknown origin involving Resident #1 and should have.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure residents' assessments accurately reflected the residents' status by failing to ensure a resident's Minimum Data Set was accurately coded for PASRR (Pre-admission Screening and Resident Review) for 2 (#21 and #54) of 6 (#21, #30, #47, #54, #76, and #91) residents reviewed for PASRR. Findings: Resident #21 Review of Resident #21's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included Paranoid Schizophrenia, Bipolar Disorder, Schizoaffective Disorder, and Major Depressive Disorder. Review of Resident #21's 142 Form Notification of Medical Certification revealed an approval for admission by the state Level II Authority from 06/01/2023 through 05/30/2024. Review of Resident #21's PASRR Level II Evaluation dated 05/17/2023 revealed the resident had a serious mental illness. Review of Resident #21's Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/08/2024 revealed Section A1500: Resident evaluated by PASRR was coded 0. No. Section A1510: Serious Mental Illness was blank. Resident #54 Review of Resident #54's clinical record revealed he was admitted to the facility on [DATE] with a diagnosis of Schizophrenia. Review of Resident #54's 142 Form Notification of Medical Certification revealed an approval for admission by the state Level II Authority from 07/10/2023 through 07/08/2024. Review of Resident #54's PASRR Level II Evaluation dated 07/13/2023 revealed the resident had a serious mental illness. Review of Resident #54's Annual MDS with an ARD of 06/05/2024 revealed Section A1500: Resident evaluated by PASRR was coded as 0. No. Section A1510: Serious Mental Illness was blank. On 08/07/2024 at 12:30 p.m., an interview was conducted with S6MDS. She verified Resident #21's Form 142 indicated Resident #21 was approved for nursing home admission by Level II authority effective 06/01/2023 through 05/30/2024. She reviewed Resident #21's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. She verified Resident #54's Form 142 indicated he was approved for nursing home admission by Level II authority effective 07/10/2023 through 07/08/2024. She reviewed Resident #54's Annual MDS assessment dated [DATE] and confirmed Section A1500 should have been coded as 1-Yes, and was not. On 08/07/2024 at 1:05 p.m., an interview was conducted with S4DON. She reviewed the aforementioned findings for Resident's #21 and #54. She confirmed the resident's Annual MDS assessments should have been coded correctly and were not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to provide appropriate and sufficient services, treatment and care according to standards of professional practice for 1 (#43) of 1 (#43) residents that were reviewed for urinary catheter. The facility failed to ensure Resident #43's urinary catheter bag was below the level of the resident's bladder. Findings: Review of Resident #43's record revealed, in part, Resident #43 was admitted to the facility on [DATE] with diagnosis of Neuromuscular Dysfunction of Bladder. Review of Resident #43's Care Plan revealed the following, in part: Problem: 02/21/2024 Resident has an indwelling catheter: for diagnosis of Neurogenic Bladder. Interventions: Position urine catheter bag below bladder. On 08/06/2024 at 2:15 p.m., an observation was made of S11CNA and S12CNA performing catheter care on Resident #43. Resident #43 was lying in bed with the catheter bag secured to the left side of her bed frame, above waist level horizontally. Immediately following Resident #43's catheter care an interview was conducted with S11CNA and S12CNA. Both S11CNA and S12CNA confirmed Resident #43's catheter bag should not be positioned above the level of her waist. On 08/06/2024 at 2:54 p.m., an interview was conducted with S4DON. She stated the expectation for urinary catheter position was for the catheter bag to be hanging below the level of the waist.

Based on record review, observation, and interview the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles for 1 (Cart A) of 2 (Cart A and Cart B) medication carts observed. The facility failed to ensure Insulin pens were discarded 28 days after the date opened. Findings: Review of the revised 10/2023, NovoLog injection package insert provided by the facility revealed, in part: Until first use: Unused NovoLog FlexPen stored at room temperature should be thrown away after 28 days. In-use: The NovoLog FlexPen you are using should be thrown away after 28 days, even if it still has insulin left in it. On 08/05/2024 at 9:15 a.m., an observation was made of Cart A with S8LPN who confirmed Resident #13 and Resident #53's Novolog insulin FlexPens were observed to have an opened date of 06/24/2024. On 08/05/2024 at 9:17 a.m., an interview was conducted with S8LPN. She stated all insulin pens should be dated when first opened, and the pen should be discarded 28 days after the opened date written on the insulin pen. S8LPN confirmed both insulin pens observed had a written open date of 06/24/2024 labeled on the insulin pens. She confirmed the Novolog insulins pens for Resident #13 and Resident #53 were available on Cart A for resident use and shouldn't have been. On 08/05/2024 at 2:45 p.m., an interview was conducted with S4DON. She was made aware of the above observations. She stated insulin pens should be labeled with an open date and discarded 28 days after that date. She confirmed the Novolog insulin pens dated 06/24/2024 should have been discarded and not available for resident use.

Based on observation, interviews, and record review, the facility failed to store food in accordance with professional standards for food service safety. This had the potential to affect 93 residents who were served from the kitchen. Findings: Review of the facility's policy titled Food Storage Labeling dated 05/2018 revealed in part, the following: Policy: The facility will ensure the safety and quality of food by following good storage and labeling procedures. Procedure: 1. Labeling a. All temperature controlled foods will be labeled. Information included on the label: name of food and date of storage. Review of the facility's policy titled Storage of Refrigerated Food dated 09/2022 revealed in part, the following: Policy: The facility ensures the quality and safety of refrigerated foods through accepted storage practices. Procedure: 4. No food is left uncovered. An initial tour of the kitchen was conducted on 08/05/2024 at 8:15 a.m., with S5DS. An observation was made of 2-open to air, unlabeled bags of shredded cheddar cheese located in the facility's refrigerator. An interview was conducted on 08/05/2024 at 8:15 a.m., with S5DS. She confirmed the aforementioned items were unsealed, unlabeled, and should have been. An interview was conducted on 08/06/2024 at 2:30 p.m. with S1ADM. He was notified of the aforementioned findings. S1ADM confirmed opened food items should be sealed and labeled.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection for 4 (#2, #28, #43, #149) of 20 resident's reviewed in the final sample. The facility failed to ensure: 1. Staff wore proper Personal Protective Equipment (PPE) while in the room of Resident's #2 and #149, who were on Droplet Precautions; 2. Staff wore proper PPE while providing care to Resident #43, who was on Enhanced Barrier Precautions; 3. Resident #43's urinary catheter bag remained off the floor; and 4. Staff performed proper infection control practices while performing wound care for Resident #28. Findings: 1. Resident #2 Review of Resident #2's Clinical Record revealed she was admitted to the facility on [DATE], and was diagnosed with Covid-19 on 07/30/2024. On 08/05/2024 at 9:15 a.m., an interview was conducted with Resident #2. She stated she currently had Covid-19. On 08/05/2024 at 1:35 p.m., an observation was made of S9CNA providing incontinence care to Resident #2. After care was provided, S9CNA removed her gown, gloves, and mask while in the resident's bathroom. S9CNA disposed of the PPE, performed hand hygiene, and exited back across the resident's room, passing the resident without a mask in place. Resident #149 Review of Resident #149's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Covid-19. On 08/05/2024 at 11:07 a.m., an observation and interview was conducted with Resident #149. There was PPE on the outside of the door with a sign indicating she was on Droplet Isolation. Resident #149 stated she currently had Covid-19. On 08/05/2024 at 1:45 p.m., an observation was made of S9CNA providing incontinence care to Resident #149. After care was provided, S9CNA removed her gown, gloves, and mask while in the resident's bathroom. S9CNA disposed of the PPE, performed hand hygiene, and exited back across the resident's room, passing the resident without a mask in place. On 08/06/2024 at 1:34 p.m., an interview was conducted with S16CNA. She stated she was assigned to Resident #149, who was Covid-19 positive. S16CNA stated before exiting Resident #149's room, she removed all PPE in the restroom, then walked passed the resident with no PPE, including a mask, to exit the room. She stated this was the facility's process. On 08/06/2024 at 2:50 p.m., an interview was conducted with S1ADM. He stated all staff removed PPE, including their mask, in the Covid-19 positive resident's bathroom, washed their hands, and then exited back across the resident's room without a mask in place. He stated this was the facility's process. 2. & 3. Review of the facility policy titled Enhanced Barrier Precautions with a revision date of 03/2024, revealed the following, in part: Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized and infected with a MDRO as well as those at increased risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices). Enhanced Barrier Precautions are indicated for residents with any of the following: Indwelling medical device examples include central lines, urinary catheters, feeding tubes, and tracheostomies. Review of the Enhanced Barrier Precautions sign posted on resident doors revealed the following, in part: Enhanced Barrier Precautions: Everyone Must: Clean their hands, including before entering and when leaving the room. Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter. Resident #43 Review of Resident #43's Clinical Record revealed she was admitted to the facility on [DATE] with a diagnosis of Neuromuscular Dysfunction of Bladder. Review of Resident #43's Care Plan revealed the following, in part: Problem: 04/21/2024-Resident has a catheter and requires Enhanced Barrier Precautions. On 08/05/2024 at 11:30 a.m., an observation was made of Resident #43 sitting in a recliner chair in her room. Resident #43's urinary catheter bag was observed on the floor by her left foot. On 08/05/2024 at 11:44 a.m., an observation was made with S7LPN of Resident #43's urinary catheter bag on the floor. She confirmed the resident's catheter bag was on the floor and should not have been. On 08/06/2024 at 11:38 a.m., an observation was made of Resident #43 sitting in her recliner chair in her room. Resident's urinary catheter bag was observed on the floor by the left wheel of her chair. On 08/06/2024 at 11:40 a.m., an observation was made with S10CNA of Resident #43's urinary catheter bag on the floor. She confirmed the resident's catheter bag was on the floor and should not have been. On 08/06/2024 at 2:15 p.m., an observation was made of S11CNA and S12CNA performing catheter care on Resident #43. S11CNA and S12CNA did not don a gown prior to performing catheter care on Resident #43. Immediately following Resident #43's catheter care an interview was conducted with S11CNA and S12CNA. S11CNA stated Resident #43 was on Enhanced Barrier Precautions. S11CNA confirmed she should have been wearing a gown while performing catheter care to Resident #43 and confirmed she had not. S12CNA confirmed she did not wear a gown and stated she was not aware she had to wear a gown when providing catheter care to Resident #43. Upon exiting Resident #43's room, two signs were observed on Resident #43's door which read: Enhanced Barrier Precautions Providers and staff must also: Wear gloves and a gown for the following high-contact resident care activities. Dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use: urinary catheter. On 08/06/2024 at 2:54 p.m., an interview was conducted with S4DON. She stated the expectation for urinary catheter position was the catheter bag should be hanging on the chair or bed off of the floor, and below the level of the waist. She stated at no point in time should the catheter bag be on the floor. She stated if a resident was on Enhanced Barrier Precautions, staff were to dress out with gloves, masks, and a gown when providing resident care, including catheter care. 4. Review of the facility's Dressing Change policy, last reviewed on 08/2021, revealed the following, in part: Steps in the Procedure: 7. Place all items to be used during procedure on the clean field. Arrange the supplies so that they can be reached. 9. Put on disposable gloves. 10. Position resident. 11. Remove dressing. Pull gloves over dressing and discard into appropriate plastic waste bag. 12. Perform hand hygiene. Put on disposable gloves. 13. Cleanse the area as ordered. Review of Resident #28's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included Peripheral Vascular Disease, Venous Insufficiency, Type 2 Diabetes Mellitus, and Cutaneous-Vesicostomy Status. On 08/07/2024 at 8:30 a.m., an observation was made of S14WC performing supra pubic catheter care for Resident #28. Prior to entering room, S14WC and S15CNA sanitized hands and donned a clean gown and gloves. S14WC removed blankets from Resident #28 and continued to touch the right side rail and remote to lower residents head. Using the same gloves, S14WC began cleansing Resident # 28's supra pubic catheter site with wound cleansing saturated gauze and the catheter itself. On 08/07/2024 at 8:45 a.m., an observation was made of S14WC performing wound care to Resident #28's left leg. An observation was made of S14WC placing xeroform, ABD dressing and gauze to Resident #28's left leg. Without changing gloves or using hand sanitizer, S14WC grabbed clean tape from bedside table with soiled gloves and secured the gauze, then placed the tape back on bedside table. During the dressing change process of the resident's left leg, an unopened ABD dressing pack fell on the floor.S15CNA picked up the unopened ABD dressing pack from the floor and placed it on the television stand. S14WC retrieved the unopened ABD dressing pack from the television stand with clean gloves and placed the dressing on the clean bedside table. After the wound to the right leg was cleansed, S14WC applied the ABD dressings on Resident #28's right leg wounds. S14WC never sanitized her hands after opening the ABD pad that had fallen on the floor. S14WC used the soiled tape from the bedside table and taped the gauze wrap. S14WC placed soiled roll of tape on top of her wound care cart and then back in the drawer. On 08/07/2024 at 8:15 a.m., an interview was conducted with S14WC. She confirmed she touched Resident # 28's blankets, side rails and remote prior to supra pubic catheter care and did not change her gloves or use hand sanitizer after touching the above mentioned items. She stated this was not a sterile procedure and it was ok to do the above. S14WC stated she was unaware she touched the tape with soil gloves. She stated if she touched the tape with soiled gloves, she should have disposed of the roll of tape. She stated it was routine to keep extra supplies on the television stand in the residents' room and she was unaware the ABD dressing package fell to the floor. She stated after she picked up the ABD dressing package from the television stand she went to the wound cart and retrieved a second ABD pad to use. She stated she then took both ABD pads and placed them on the clean bedside table. She confirmed she used the both ABD pads on Resident #28's right leg wounds. On 08/07/2024 at 11:00 a.m., an interview was conducted with S14CNA. She confirmed the ABD dressing package dropped to the floor and she picked it up and placed on the television stand. On 08/07/2024 at 9:35 a.m., an interview was conducted with S4DON. She was made aware of the above findings. She stated she expected the wound care nurse to change gloves and use hand sanitizer after touching Resident #28's blankets, side rails and remote prior to cleansing the supra pubic site and catheter. S4DON confirmed tape should not be touched with soiled gloves and placed back on the clean bedside table, on the wound care cart, and then back in the drawer. She stated extra wound care supplies should not be placed on the television stand. She confirmed the ABD dressing that was dropped on the floor should have been discarded, not placed on the bedside table and used on Resident #28's wound.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to develop a residents' plan of care for 1 (#1) out of 10 total sampled residents reviewed. The facility failed to develop a person-centered care plan for constipation for Resident #1 when she returned from a hospital stay on 01/19/2024. Findings: Review of the clinical record for Resident #1 revealed the resident was admitted to the facility on [DATE] and re-admitted on [DATE]. The resident had diagnoses that included Traumatic Subdural Hemorrhage, Rhabdomyolysis and Constipation. Review of Resident #1's Quarterly MDS with ARD 01/25/2024 revealed her BIMS was blank, which meant unable to complete an interview. Review of Resident #1's hospital discharge records dated 01/19/2024 revealed, in part: New medications: Senna-docusate 8.6-50 take 1 tablet by mouth 2 times daily as needed for constipation. Active diagnosis: Constipation Review of Resident #1's care plan revealed no care plan developed for her new diagnosis of constipation. On 04/11/2024 at 1:00 p.m., an interview was conducted with S12CPN. She reviewed Resident #1's care plan. She verified Resident #1 was not care planned for constipation and should have been when she returned from the hospital on [DATE] with a new diagnosis of constipation. On 04/11/2024 at 1:35 p.m., an interview was conducted with S2DON. She reviewed Resident #1's care plan and confirmed she should have been care planned for constipation when she returned from the hospital on [DATE] with a new diagnosis of constipation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to notify the resident's physician and representative of changes in condition for 1 (#1) of 6 (#1, #2, #3, #R1, #R2, and #R3) residents reviewed for notification of change. The facility failed to: 1. Notify the resident's physician and family after identifying a new sacral wound for Resident #1; and 2. Notify the physician when Resident #1 did not have a bowel movement beyond 3 days. Findings: 1. Review of the facility's policy dated 09/2017 and titled, Change in Resident Medical Status revealed, in part: A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s), when there is- 1. A significant change in the resident's physical, mental, or psychosocial status; (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications.) 2. A need to alter treatment significantly; (that is a need to discontinue or change and existing treatment due to adverse consequences, or to commence a new form of treatment.) Review of the clinical record for Resident #1 revealed the resident was re-admitted to the facility on [DATE] with diagnoses that included Pressure Ulcer of Sacral Region and Constipation. Review of Resident #1's Nurse's Notes revealed, in part: 12/24/2023 at 1:12 p.m., this nurse was notified by CNA that resident had a skin breakdown on sacral area. This nurse assessed along with S4RNS. S4RNS performed wound care to sacral area. 12/25/2023 at 6:28 a.m., treatment done to sacral wound. At 6:02 a.m., Responsible Party was notified. At 6:04 a.m., S9MD was notified. Review of the medical record for December 2023 revealed Resident #1's body audit on 12/23/2023 revealed no changes in skin and no skin breakdown. Further review revealed on 12/24/2023, Resident #1 had an Unstageable Sacral Ulcer. On 04/09/2024 at 12:40 p.m., a telephone interview was conducted with S13CNA. She said she was working on 12/24/2023 when she noticed a small quarter size reddened area with no break in skin. She stated she notified the nurse on the hall. On 04/09/2024 at 1:23 p.m., a telephone interview was conducted with S4RNS. S4RNS stated he could not recall the wound on Resident #1, but if he notified the MD or the family of a new wound, it would have been documented. On 04/09/2024 at 4:30 p.m., an interview was conducted with S5LPN. She said she was assigned to Resident #1 on 12/24/2023, the day her new sacral wound was found. She said S13CNA reported the wound to her and she and S4RNS assessed the wound. She said S4RNS conducted the skin assessment and performed wound care. She said she didn't notify the family or physician because it was the responsibility of the RN. On 04/11/2024 at 9:40 a.m., an interview was conducted with S3ADON. She said Resident #1's family and physician should have been notified on 12/24/2024, the day the new sacral wound was identified. On 04/11/2024 at 3:15 p.m., an interview was conducted with S2DON. She said staff should have notified Resident #1's family and the physician the day her wound was identified. 2. Review of the facility's policy dated 05/2011 and titled, Bowel Movement Monitoring revealed, in part: Policy: Bowel movements will be monitored on a daily basis in order to help prevent constipation and impaction. Procedure: 1. All residents will be monitored daily for bowel movements. 2. The nurse will review the documentation to determine if a resident has not had a bowel movement in 3 days, then a laxative will be given after notifying the physician and obtaining an order if there is no standing order. 3. Nursing observation of resident's condition and/or symptoms, as well as outcomes, must be documented in the Nurse's Notes. Review of nursing documentation for Resident #1 including Bowel Movement Records and Nurse's Notes revealed Resident #1 did not have a bowel movement between 03/08/2024 and 03/22/2024. Further review of records revealed the physician was not notified. On 04/11/2024 at 3:15 p.m., an interview was conducted with S1DON. She confirmed there was no documented bowel movements for Resident #1 between 03/08/2024 and 03/22/2024 and no documentation the physician had been notified. She confirmed the nurse's should have notified the physician when there was no bowel movement after 3 days. On 04/11/2024 at 4:10 p.m., an interview was conducted with S9MD. He stated he knew Resident #1's health had declined, her appetite was poor, she was not drinking much, and she had become bedbound. He verified he was not notified of Resident #1 not having a bowel movement between 03/08/2024 and 03/22/2024. He said he expected the nurses to notify him if the resident hadn't had a bowel movement for more than 3 days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement a comprehensive person-centered care plan by failing to follow physician's orders for 2 (#6 and #67) of 32 sampled residents reviewed for care plans. Findings: Review of the facility's policy titled Physician Orders revealed, in part: It is the policy of this facility that all physician's orders will be implemented timely and carried out in a professional manner. Verbal or telephone orders are considered to be in writing when dictated or given by the attending physician and later signed or initialed by him/her. Telephone orders are to be received/transcribed by a nurse. When the nurse receives a verbal (or telephone) order after the initial admit/readmit order, the nurse will transcribe the order to for NS-664-New Physician's Orders or enter the order electronically. The order shall in a timely manner be signed and dated by the nurse receiving the order. The order shall be transcribed on the MAR or other appropriate form. Licensed nurses are responsible for following physician orders. Resident #6 Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE] with diagnosis to include Type 2 Diabetes Mellitus. Review of Resident #6's Weight Change History from 08/15/2023 to present revealed: 08/16/2023 Weight 173.00 lbs. 09/06/2023 Weight 185.20 lbs. An interview was conducted on 09/26/2023 at 1:55 p.m. with S4ADON. She stated she was responsible for entering resident's weights into the care plan. She confirmed she received an order from S5MD in August 2023 for Resident #6 to receive weekly weights. She confirmed she did not implement the order. She confirmed Resident #6 did not receive weekly weights in August or September 2023. An interview was conducted on 09/27/2023 at 9:34 a.m. with S5MD. He confirmed ordering weekly weights for Resident #67 in August 2023. He confirmed the weekly weights were not completed as ordered and should have been. He confirmed the nursing staff should follow physician orders. Resident #67 Review of Resident #67's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included the following; Type 2 Diabetes Mellitus with Diabetic Neuropathy. Review of Resident #67's most recent Minimum Data Set (MDS), indicated the resident had a Brief Interview of Mental Status (BIMS) of 15, which indicated she was cognitively intact. Review of Resident #67's current Physician Orders revealed an order dated 08/16/2023 for Novolog 70/30 flex pen 40 units subcutaneous every evening. Review of Resident #67's Physician's Progress Notes dated 08/16/2023 revealed Novolog 70/30 40 units subcutaneously at dinner time was added due to Type II Diabetes. Review of the facility's in-service document dated 08/22/2023 revealed the following, in part: Medication error education in-service was completed with S8LPN regarding the missed order written on 08/16/2023 for Novolog 70/30 40 Units subcutaneous every evening. An interview was conducted on 09/25/2023 at 9:01 a.m. with Resident #67. The resident stated she did not receive insulin the first week after she was admitted to the facility. An interview was conducted on 09/27/2023 at 1:04 p.m. with S6NP. She stated on 08/16/2023, she wrote an order for Resident #67 to receive Novolog 70/30 40 units every evening. She stated the facility failed to implement the order until 08/22/2023 and the resident did not receive insulin during that time. She stated she expected the nurses to follow physician orders. An interview was conducted on 09/27/2023 at 1:51 p.m. with S8LPN. He stated he was responsible for admitting Resident #67 to the facility during the night shift on 08/15/2023. He stated during the admission, he noted she did not have an order for insulin and should have. He stated he notified S6NP the morning of 08/16/2023 that Resident #67 did not have an order for insulin. He stated S6NP came to the facility on [DATE] and wrote insulin orders for the resident. He stated he should have implemented the order by entering it into the computer system right away. He confirmed he failed to input the order for Resident #67's insulin and the resident did not receive the medication from 08/15/2023 to 08/21/2023. An interview was conducted on 09/27/2023 at 1:54 p.m. with S7PDON. She stated on 08/22/2023 S10LPN completed a routine chart audit and noted Resident #67 had an order for Novolog 70/30 insulin in the chart that had not been entered into the computer system. She stated S6NP was notified and the order was implemented. She confirmed Resident #67 did not receive insulin from 08/15/2023 to 08/21/2023 and should have. An interview was conducted on 09/27/2023 at 2:18 p.m. with S10LPN. She stated she was auditing Resident #67's chart on 08/22/2023 and noticed an order for Novolog 70/30 insulin that hadn't been placed into the computer system. She stated she notified S9LPN about the missed order. An interview was conducted on 09/27/2023 at 2:22 p.m. with S9LPN. She stated S10LPN notified her of a missed insulin order for Resident #67 on 08/22/2023. She confirmed Resident #67 did not receive insulin from 08/15/2023 to 08/21/2023 and should have.

Based on observations, record review, and interviews, the facility failed to ensure medications were properly stored in 1 (Med Room A) of 2 (Med Room A and Med Room B) Medication Storage Rooms observed for medication storage. Findings: Record review of the facility's policy titled Medication Rooms revealed in part: Procedure: 1. Refrigerators d. Check for discontinued and expired medications. 2. Locked Medication Room: d. Check for discontinued and expired medications and supplies. An observation was conducted on 09/25/23 at 1:50 p.m. of Med Room A. Two Daptomycin 500mg/50ml Eclipse IV devices were observed with expiration dates of 09/21/2023 in the locked Medication refrigerator. An interview was conducted on 09/25/2023 at 1:51 p.m. with S3LPN. She confirmed two Daptomycin Eclipse IV devices present in Med Room A's Medication refrigerator were expired and should have been discarded. An interview was conducted on 09/25/23 at 2:05 p.m. with S2DON. She confirmed two Daptomycin Eclipse IV devices present in Med Room A's Medication refrigerator were expired and should have been discarded.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure each resident remained free from verbal and physical abuse by another resident for 2 (#89 and #46) of 26 residents reviewed in the initial screening for abuse. Findings: Review of the facility's policy Resident Abuse revealed in part: Policy: Conduct detrimental to resident care that results in neglect or abuse of any resident is strictly prohibited. Review of the facility's policy Resident Rights revealed in part: All residents in a long-term care facility have rights guaranteed to them under Federal and State law. Residents residing at this facility will be guaranteed a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. These rights include: 31. To be free from abuse, neglect, misappropriation of resident property and exploitation. Resident #89 Review of Resident #89's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #89's MDS with an ARD of 09/14/2022 revealed the facility assessed her to have a BIMS of 15, which indicated she was cognitively intact. Review of Resident #89's signed written statement, dated 08/10/2022, regarding the physical altercation with Resident #46 on 08/07/2022 revealed in part: Resident #89 was sitting at the nurses' station corner waiting on the nurse to give morning medications when Resident #46 passed her and bumped into her with her wheelchair. Resident #89 stated Excuse me at which point Resident #46 stated move you fat f****** cow. Resident #89 then told Resident #46 not talk to her that way and called her an old hag. Resident #46 then stated what are you gonna do about it?. Resident #46 then came up behind Resident #89 and started swinging. Resident #89 turned to block her but Resident #46 hit her in the face and arm. Resident #89 stated she then began yelling for help from staff. Resident # 46 Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE]. Review of Resident #46's MDS with an ARD of 08/19/2022 revealed the facility assessed her to have a BIMS of 8, which indicated she was moderately cognitively impaired. Further review revealed Resident #46 was assessed by the facility to have a BIMS of 14 on 06/08/2022, which indicated she was cognitively intact. Review of Resident #46's signed written statement, dated 08/10/2022, regarding the physical altercation with Resident #89 on 08/07/2022 revealed in part: Resident #46 stated Resident #89 said, Hit me! Hit me! I was angry. She is always in the way. Review of Resident #46's Nurses Notes indicated on 08/07/2022 around 6:10 p.m., Resident #46 and Resident #89 were in the same area near the nurses station where they began a verbal altercation with each other. The situation escalated rapidly as each began to shout profanities and insults to the other. Before staff could separate the residents, Resident #89 shouted for Resident #46 to punch her, at which time, Resident #46 stood and punched Resident #89 in the face. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed she was caring for both residents at the time of the physical altercation. She stated Resident #89 was seated in her wheelchair drinking coffee at the nurse's station when Resident #46 bumped into her with her own wheelchair when trying to get by. She stated Resident #89 then made a rude remark to her about not being able to see well and bumping into her. She stated Resident #46 then spun around towards Resident #89 and they began to exchange rude remarks to each other. She stated Resident #46 hit Resident #89 in the face with her hand. She confirmed staff heard the altercation start but were not able to get them separated before Resident #46 hit Resident #89. An interview was conducted on 10/12/2022 at 2:10 p.m. with S2DON. She confirmed a physical altercation took place on 08/07/2022 between Resident #89 and Resident #46. She confirmed the facility determined Resident #46 wheeled herself behind Resident #89 but could not get through because Resident #89's wheelchair was blocking the path. She stated some words were exchanged between the two residents. She stated Resident #46 stood from her wheelchair, walked over to Resident #89 and hit her in the face. Resident #89 then pushed Resident #46 away.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide respiratory care consistent with professional standards by failing to ensure oxygen tubing was properly labeled and/or changed in a timely manner for 7 (#46, #64, #70, #77, #89, #192, and #343) of 9 residents reviewed in the initial screening for oxygen therapy. Findings: Review of Facility Policy titled: Infection Control Oxygen Equipment Cleaning, revealed in part: Use disposable tubing, masks, and cannulas for patients receiving oxygen therapy. This equipment is to be discarded as this procedure dictates. 7. Tubing should be replaced every 7 days. 8. Masks should be replaced every 7 days. 9. Cannulas should be replaced every 7 days. 10. When not in use, store the mask/ cannula in a plastic bag clearly labeled with the resident's name and date. Resident #46 Review of Resident #46's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part, Chronic Obstructive Pulmonary Disease (COPD) and Asthma. Review of Resident #46's MDS with an ARD of 08/19/2022 revealed the facility assessed her to require the use of oxygen therapy. Review of Resident #46's Physician's Orders revealed, in part, an order written on 08/15/2022 to check oxygen saturation every shift. If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #46's most recent Care Plan revealed, in part, resident has diagnoses of COPD, asthma and complains of shortness of breath at times and should receive oxygen as ordered. Review of Resident's #46's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters per minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 10:00 p.m., 10/02/2022 at 2:00 p.m., 10/03/2022 at 6:00 a.m., 10/04/2022 at 6:00 a.m., 10:00 p.m., 10/05/2022 at 6:00 a.m., 10/06/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10/08/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/09/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/10/2022 at 6:00 a.m., 10:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., and 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m. On 10/10/22 at 9:45 a.m., an observation was made of Resident #46's oxygen tubing with no date present. On 10/10/22 at 12:43 p.m., an observation was made of Resident #46 with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/11/22 at 10:05 a.m., an observation was made of Resident #46 with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/12/2022 at 10:45 a.m., an interview was conducted with S6LPN. She confirmed there was no date present on Resident #46's oxygen tubing but should have been. Resident #64 Review of Resident #64's Clinical Record revealed resident was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #64's Physician's Orders revealed, in part, an order written on 03/15/22 for continuous oxygen at 3 liters per minute via nasal cannula. On 10/11/22 at 10:48 a.m., an observation was made of Resident #64 with oxygen in use via nasal cannula. No date noted on oxygen tubing On 10/11/22 at 10:11 a.m., an interview was conducted with S4LPN. She stated the oxygen tubing should be changed weekly. She confirmed Resident #64's oxygen tubing was not dated but should have been. Resident #70 Review of Resident #70's Clinical Record revealed resident was readmitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure with Hypoxia, Severe Persistent Asthma and Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #46's Physician's Orders revealed, in part, an order written to check oxygen saturation every shift. If less than 92%, administer as needed oxygen at 2 liters per minute via nasal cannula with follow up to evaluate effectiveness. On 10/10/2022 at 11:51 a.m., an observation was made of Resident # 70 lying in bed with oxygen in use via nasal cannula. No date noted on oxygen tubing. Resident #77 Review of Resident #77's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses including, in part, Chronic Obstructive Pulmonary Disease (COPD). Review of Resident #77's MDS with an ARD of 09/20/2022 revealed the facility assessed her to require the use of oxygen therapy. Review of Resident #77's Physician's Orders revealed, in part, an order written by S8MD on 05/05/2021 to check oxygen saturation every shift. If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident's #77's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 6:00 a.m., 10:00 p.m., 10/02/2022 at 10:00 p.m., 10/03/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/04/2022 at 2:00 p.m., 10/05/2022 at 6:00 a.m., 2:00 p.m., 10/06/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/08/2022 at 10:00 p.m., 10/09/2022 at 10:00 p.m., 10/10/2022 at 6:00 a.m., 2:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., and 10/13/2022 at 6:00 a.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. On 10/10/22 at 12:49 p.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. On 10/11/22 at 10:05 a.m., an observation was made of Resident #77 in her wheelchair with oxygen in use and oxygen tubing dated 09/30/2022. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #77's oxygen tubing was dated 09/30/2022 and out of date. Resident #89 Review of Resident #89's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part: Chronic Obstructive Pulmonary Disease (COPD); Acute on Chronic Respiratory Failure; Shortness of Breath and Wheezing. Review of Resident #89's MDS with an ARD of 09/14/2022 revealed the facility assessed her to have a BIMS of 15, which indicated she was cognitively intact. Further review revealed she was assessed to require the use of oxygen therapy. Review of Resident #89's Physician's Orders revealed, in part, an order written by S7MD on 09/09/2022 to check oxygen saturation every shift. If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #89's most recent Care Plan revealed, in part, resident has impaired gas exchange and should receive oxygen as ordered. Review of Resident's #89's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 6:00 a.m., 2:00 p.m. and 10:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/01/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/02/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/03/2022 at 2:00 p.m., 10:00 p.m., 10/04/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/05/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/06/2022 at 2:00 p.m., 10:00 p.m., 10/07/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/08/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/09/2022 at 2:00 p.m., 10:00 p.m., 10/10/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., 10/11/2022 at 6:00 a.m., 2:00 p.m., 10/12/2022 at 6:00 a.m., 2:00 p.m., 10:00 p.m., and 10/13/2022 at 6:00 a.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #89 in her wheelchair with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/10/22 at 12:45 p.m., an observation was made of Resident #89 in her wheelchair with oxygen in use via nasal cannula. No date noted on oxygen tubing. On 10/11/22 at 10:05 a.m., an observation was made of Resident #89 lying in bed with oxygen in use via nasal cannula. No date noted on oxygen tubing. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #89's oxygen tubing was not dated but should be. Resident #192 Review of Resident #192's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses, which included, in part: Chronic Obstructive Pulmonary Disease (COPD); Heart Disease with Heart Failure and Morbid Obesity. Review of Resident #192's MDS with an ARD of 08/03/2022 revealed the facility assessed him to have a BIMS of 15, which indicated he was cognitively intact. Further review revealed he was assessed to require the use of oxygen therapy. Review of Resident #192's Physician's Orders revealed, in part, an order written by S7MD on 09/17/2022 to check oxygen saturation every shift. If less than 92%, administer as needed oxygen at 2 liters/minute via nasal cannula with follow up to evaluate effectiveness. Review of Resident #192's most recent Care Plan revealed, in part, resident has a diagnosis of COPD and often uses oxygen via nasal cannula at 2 liters/minute. Review of Resident's #192's MAR for October 2022 revealed, in part, the following task: Check oxygen saturation every shift, if less than 92% administer as needed oxygen at 2 liters/minute via nasal cannula. Oxygen saturation to be documented at 12:00 p.m. and 8:00 p.m. Further review revealed oxygen saturations below 91% and documented supplemental oxygen in use on the following dates/times: 10/03/2022 at 12:00 p.m., 8:00 p.m., 10/04/2022 at 8:00 p.m., 10/05/2022 at 8:00 p.m., 10/06/2022 at 8:00 p.m., 10/07/2022 at 8:00 p.m., 10/08/2022 at 8:00 p.m., 10/10/2022 at 12:00 p.m., and 8:00 p.m. On 10/10/22 at 10:20 a.m., an observation was made of Resident #192 in bed with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/10/22 at 12:40 p.m., an observation was made of Resident #192's oxygen tubing dated 09/30/2022. On 10/11/22 at 10:05 a.m., an observation was made of Resident #192's oxygen tubing dated 09/30/2022. An interview was conducted on 10/12/2022 at 10:45 a.m. with S6LPN. She confirmed Resident #192's oxygen tubing was dated 09/30/2022, which was outdated. Resident #343 Review of Resident #343's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses, which included, in part: Pulmonary Hypertension, Chronic; Heart Failure, Personal history of COVID-19 and Personal history of Bilateral Pneumonia. Review of Resident #343's Physician's Orders for October 2022 included an order to check oxygen saturation every shift as needed, if less than 92% administer as needed Oxygen at 2 liters per minute via nasal cannula as needed. Review of Resident # 343's Care plan dated 9/23/22 revealed diagnoses including Upper Respiratory Infection, Pneumonia, Respiratory Failure and COPD with oxygen to be used as needed. On 10/10/22 at 9:00 a.m., an observation was made of Resident#343 with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/11/22 at 9:06 a.m., an observation was made of Resident #343 with oxygen in use via nasal cannula. The oxygen tubing was dated 09/30/2022. On 10/11/22 at 10:11 a.m., an interview was conducted with S2LPN. She confirmed Resident #343's oxygen tubing was dated 09/30/2022 but should have been changed on or before 10/07/2022. On 10/12/22 at 9:40 a.m., an interview was conducted with S2LPN. She confirmed she had been educated on the facility's policy regarding oxygen therapy. She stated policy is to change oxygen tubing and/or the oxygen mask every 7days and confirmed all oxygen supplies should be dated when changed. On 10/13/2022 at 10:30 a.m., an interview was conducted with S2DON. She confirmed all oxygen tubing and masks should be changed every 7 days with the date it was changed written on the equipment. She further confirmed any oxygen equipment dated 09/30/22 should have been changed on or before 10/07/2022 and any undated equipment should have been changed immediately.